the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.

Wednesday, April 21, 2010

significant moments

i hate paediatrics. people who don't understand the life of surgery may think this means i don't like children, but in fact the contrast is true. surgery is suffering and heartache. surgery is pain and misery. it is stuff children are not supposed to experience. children are supposed to be caught up in the joys of life. they are supposed to play and smell the roses along life's paths. pain will come later, but childhood is supposed to be a sanctuary, albeit temporary from the harsh realities of life. and when life really gets harsh, you may need to come to me.

i once spoke about a very special boy who crossed my path. his death still haunts me but there was another incident which drove the wedge between myself and paediatric surgery forever.

it was during my thoracic rotation. to be honest it was one of the more enjoyable rotations. they actually occasionally allowed me to do a thoracotomy or two. most of the other disciplines used us as their underlings to get the ward work done. of course in thoracics we were also used for this but at least there was a payoff.

one day myself and a rotating registrar from another university were sent to draw the preoperative bloods on all the theater cases for the next day. i was fine with this. i secretly hoped i'd find a case i could do myself if the powers that be smiled upon me the next day.

we soon found ourselves in the paediatric ward. there was a girl of about eight years old that was going to be operated the next day. she was apparently born with a severe heart abnormality and had undergone some sort of procedure at birth that had enabled her to survive these last eight or so years. however she was now due to undergo a slightly more permanent operation that would hopefully get her through the next thirty or so years. thereafter she would apparently most likely die. the tragedy of it was already something that weighed heavily on me. it seemed so unfair. but when i saw her i was shaken.

she was blue, a colour i've never thought looks good in someone's face. she also passively sat there trying not to expend any unnecessary energy. i could see she was puffing to try to get enough oxygen. an eight year old is supposed to enjoy life, not struggle for every breath. my normal heart went out to her.

the sister called her to go with us to the procedure room, a room in most paediatric wards that the children fear because they know it is associated with pain. she, however just looked at us with a tired forlorn expression on her face. it seemed too much effort for her to be scared.

in those days we used to draw blood from children from the internal jugular vein (in the neck). i'm sure there are readers that will feel this is cruel but drawing blood from a child is cruel to start with. we were good at the jugular approach and at least we knew we would get it right with the first attempt which is a darn sight less cruel than multiple prolonged attempts from another site. we got to work. the other registrar was going to hold her in position and i was going top draw the blood.

he placed her on the bed and got her position right. she didn't resist at all. if anything, her body lay limply waiting for the inevitable. the registrar tilted her head to expose the neck and i readied the syringe. then i went for it. she went berserk. she started screaming and kicking like mad. the registrar held her down and the needle advanced. i concentrated on getting it right and that meant i had to get my mind off her experience of emotional trauma. when the blood started flowing freely into the syringe i relaxed a bit and listened to what she was screaming between her tears.

my tswana is not very good but it was good enough to understand what she was saying. the registrar holding her was also a tswana and she was speaking to him, not me.

"uncle, uncle, save me from the white man!" she cried over and over again. he quietly whispered in her ear that it was going to be alright, but she would not be consoled. i would not either. like all children she couldn't reason that, although what she was experiencing was unpleasant, we were doing it in her best interests. all she knew was that the white man was stabbing her in the neck with a needle and it traumatised her. it was the sort of thing that you don't easily forget. it was a significant moment for her.

the next day i was tasked with assisting with a few smaller cases while the prof, another consultant and the senior registrar attempted the fancy operation on the eight year old girl's heart. i wouldn't get to see how it went, which, to tell the truth at that time, suited me fine. however, as it turned out, the prof ended up walking up and down between the two theaters and giving us a sort of running commentary.

"how's it going?" asked the registrar operating with me.

"not great." replied the prof. and then he dropped one of his typical gems.

"eintlik is onsbesig met eenmoersefokkenpalliatiewepooginglangsaan" (we're actually busy with one massive f#cken palliative operation next door). he then gave his usual inappropriate giggle. i couldn't even manage a grimace.

that night i was on call. part of my job being on call in thoracics was to look after the thoracic icu patients. the girl was one of them and would be my responsibility. from the first moment things went badly. then they quickly got worse. i did all i could think to do, but as i looked at her small body lying there in the big icu bed with tubes sticking out of her all over i realised the odds were stacked against us. i phoned the prof to ask what else i needed to do and followed his advice. however just before he hung up he said that thereafter there was nothing more we could do. when he omitted his usual giggle i knew she would die.

a few hours later it was my duty to give the prof a courtesy call to tell him the girl had passed away. he simply said thanks that i had informed him. then i was left alone with my thoughts.

i thought of her looking at me the previous day with no more fight left in her tired body. i thought of the years she had had a semi-existence and had missed out on all the things that make life magical for children. i thought of whether she had had any significant moments that had put a smile on her face despite her circumstances. and then i thought about her last significant moment, the one that had traumatised her for the rest of her life, the one where the white man had driven a needle into her neck despite her vociferous supplications for him not to do it. we are supposed to make life better. we are supposed to enable people to go back into the world to enjoy the beauty and wonder of life. what we do is not an end in itself but a means to an end. the point is to have a better life and that i did not give her by any stretch of the imagination. i felt devastated, but i was alive to feel devastated. she would never feel again. i no longer wanted to go on with this painful profession. i could no longer hold back the tears. it was a significant moment in my life.

beautifully haunting post, bongi. sorry for that patient and her family...sorry for you. i trained where we had a pediatric trauma center attached to the adult trauma center, and my time there, although difficult, made me appreciate how lucky we are when we have healthy children, giggling and carrying -on around us.

It is a profound memory ..one you would prefer not to have had, but perhaps you were exactly the person to do it. Perhaps someone else may not have been as compassionate. Your heart went out to her the moment you 1st saw her.

I love your writing Bongi. I haven't been out in the blogosphere commenting like I was ..but I have been reading. You also have a gift for writing and bringing your readers into the experience.

I know I rarely comment here, but I read. I hope you don't mind my commenting now.

My heart went out to you, and the girl.

While what you do sometimes causes pain, you also intercede to prolong life. Those of us that need your help, are given a second chance, sometimes. You give us a chance to feel whole again. Changed, but whole. You give us the chance to hold our loved ones again. We are given the time to tell them we love them. You give us the chance to feel the sun on our face, and the warmth on our skin. You give us hope for a few more tomorrows, maybe years....maybe a cure.

Don't let that moment with the child stay with you. You know, children are very smart, and while your drawing the blood hurt her at the time, later she understood you were trying to help her. Children know and understand more than we give them credit for. I'm sure it was discussed after the fact.

It's an awful thing when the children suffer. I agree, children should be free to play and enjoy the life they were given, not have to suffer illness, pain, and death.

angel, of course i don't mind you commenting here. you are always welcome to comment. in fact, thank you for your comments.

having said that i must disagree with some of the things you said. the girl in question never got a chance to understand. she was in a strange scary place with all sorts of horrible things happening. then she went to theater and then she was dead. there was no discussion and there was no resolution. and the death was final.

also i think these things need to stay with me. every time i treat a child i need to step back and ignore their screams so that i can do my job. if i don't allow stories like this to stay with me to keep the balance i will truly lose the humanity of it.

"Aeschylus held that there was suffering so great that, even in our sleep, it dripped upon the heart until "in our own despair, against our will" comes a terrible wisdom."From an article about the terrible death of a little girl.Maybe that wisdom is all we have sometimes.

Most of us choose our own torments, or maybe they choose us in a way we can't refuse.

I see some doctors who seem to choose specialties that allow them to keep a distance between themselves and their patients and the patients' families. I neither envy them nor think of them as selfish in some way.

My personal approach is to try to stay human, to try to immerse myself in the sorrow, not to "feel their sorrow", you can only feel your own, but it's our own demon we must face sooner or later, and it won't help to ignore or run away from it.

I've never been able to interact with children as patients- it is such an odd situation. Children should be happy, children should be full of energy, children should never have to be in pain. They should never look at me with fear in their eyes.

It doesn't always happen that way, and that's why I admire pediatric physicians more than anybody else.

Hey Bongi, I always pictured you as black, not that this matters, just that I needed an imaginary face/body to go with the stories. Can you tell us a bit more about yourself? Like how old are you? How tall are you? What actor do you look like?

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the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.